Lensectomy After Radial Keratotomy: 1-Year Follow-Up

Int Ophthalmol (2019) 39:2561–2568

https://doi.org/10.1007/s10792-019-01104-w (0123456789().,-volV)(0123456789().,-volV)

ORIGINAL PAPER

Lensectomy after radial keratotomy: 1-year follow-up

Jose´ F. Alfonso . Ba´rbara Martıń-Escuer . Alberto Domıńguez-Vicent . Robert Monte´s-Mico´ . Luis Fernańdez-Vega

Received: 20 January 2019 / Accepted: 5 April 2019 / Published online: 11 April 2019 Ó Springer Nature B.V. 2019

Abstract and postoperative problems occurred. The mean Purpose To report visual and refractive results in logMAR UDVA significantly improved from radial keratotomy (RK) patients that underwent a 0.7 ± 0.3 to 0.4 ± 0.2 at 6 months, and 0.3 ± 0.2 at cataract surgery with a monofocal intraocular lens 12 months postoperatively. By the end of the follow- (IOL) implantation with 1 year of follow-up. up period, about 60% of the eyes achieved 20/25 or Methods Twenty-eight eyes of 15 patients with better CDVA, 25% of the eyes gained three or more cataract and the previous RK were included. All eyes lines of visual acuity, and two eyes had lost one or underwent phacoemulsification and monofocal IOL more lines of visual acuity. The mean spherical implantation. IOL power calculation was done using equivalent improved from - 1 ± 6.00 to the Double-K formula of Aramberri. The preoperative - 0.75 ± 1.1 D by the end of the follow-up, and versus postoperative corrected distance visual acuity about 60% of the eyes were within ± 1D at (CDVA) and the uncorrected distance visual acuity 12 months after the surgery. No intra- and postoper- (UDVA) values were used to assess the efficacy and ative problems occurred. safety of the surgery; meanwhile, the achieved versus Conclusions Pseudophakic monofocal IOL implan- the expected refractive outcomes postoperatively were tation offers good visual acuity recovery and accept- used to assess the predictability. able refractive correction in RK patients after 1-year Results Phacoemulsification and IOL implantation follow-up. was performed successfully in all eyes, and no intra- Keywords Radial keratotomy Á Phacoemulsification Á Cataract Á Intraocular lens Á & J. F. Alfonso ( ) Á B. Martıń-Escuer Á Visual acuity L. Fernańdez-Vega Fernańdez-Vega Ophthalmological Institute, Avda. Dres. Fernańdez-Vega 114, 33012 Oviedo, Spain e-mail: [email protected] Introduction J. F. Alfonso Á L. Fernańdez-Vega Surgery Department, School of Medicine, University of Oviedo, Oviedo, Spain Radial keratotomy (RK) was introduced around 1970, and it was the most common surgery for 20 years, A. Domıńguez-Vicent Á R. Monte´s-Mico´ when the corneal laser surgery became more popular. Optics and Optometry and Vision Sciences Department, Faculty of Physics, University of Valencia, Valencia, As it was reported, the main postoperative complica- Spain tions after RK were diurnal fluctuations, hyperopic or 123 2562 Int Ophthalmol (2019) 39:2561–2568 myopic shift, and poor predictability [1, 2]. Neverthe- from all patients before the surgery in accordance with less, although RK is not commonly used, patients who the Declaration of Helsinki. had undergone RK in the past have aged and have developed cataract. Unfortunately, there are few Surgical technique challenges to calculate correctly the intraocular lens (IOL) power, such as the hyperopic shift, [3] the The peribulbar anesthetics used were the lidocaine at difficulties to determine the effective lens position, [4] 2% and bupivacaine at 0.5%. Thirty minutes before and the difficulties to calculate the true corneal the surgery, cycloplegic (10 mg/ml) and phenyle- curvature [5, 6]. In fact, several studies have reported phrine (100 mg/ml) eyedrops were instilled. Before IOL power accuracy in eyes previously had RK using starting with the surgery, the eye was disinfected with corneal topographers [7, 8] and tomographers [9, 10]. povidone-iodine at 5%, and the eyelids were disin- Based on the results published, it seems as if there is no fected with the same solution at 10%. single method that it is superior to other in calculating When the RK had four or eight cuts, the main the IOL power [11]. A recent study assessed the incision was done between the RK cuts. The cataract accuracy of several IOL formulas in eyes with RK and surgery was done through a scleral incision when the concluded that further improvements are needed for RK had more cuts. In any case, a 2.2-mm keratome IOL power calculations in this group of patients [11]. was used to create the main incision, and if it was At the same time, other publications assessed possible, on the steepest meridian to compensate up to refractive and visual outcomes of IOL implantation 1.25 D of astigmatism. Then, the cohesive viscoelastic in eyes with RK [12–14]. Concretely, these publica- was introduced into the eye, and a uniform and tions are case reports that provide results of multifocal centered capsulorhexis of 5 mm of diameter was done IOL implantation and concluded that this lens design to ensure that it covers the optic of the IOL. After this, might be beneficial for patients who previously the dispersive viscoelastic was injected to protect the underwent a RK. On the other hand, another study eye structures during the crystalline lens emulsifica- reported visual outcomes and complications after tion. Then, a capsular tension ring and IOL are cataract surgery using different incision lengths in implanted. Finally, acetylcholine (10 mg/ml) and the eyes with the previous RK [15]. All in all, the results of antibiotic (cefuroxime, 1 mg/ml) were injected. In that study showed that the more RK incisions, the order not to use stitches, trapezoidal incisions were smaller clear incision size. To date, there is only one used when the surgery was done through the cornea, study assessing the visual and refractive changes in and tunneled incisions when the surgery was done RK patients after cataract surgery during a long through the sclera. follow-up. The aim of the present study was to report visual Intraocular lens power calculation and refractive results in RK patients that underwent a cataract surgery with a monofocal IOL implantation The biometers used to calculate the IOL were the during 1-year follow-up. The results of this study Ocuscan (Alcon, USA), and the IOLMaster 500 and might help to elucidate a valid surgical solution for 700 (Carl Zeiss Meditec, Jena, Germany); meanwhile, cataract patients who previously had this type of the formula used to calculate the IOL power was the corneal surgery. Double-K [4]. This formula uses the pre-refractive surgery K value to calculate the effective lens position, and the post-refractive surgery K value for the IOL Methods power calculation. In all cases, the target was fixed between - 1.50 and - 1.0 D. If the K value pre-RK This retrospective study considered the postoperative was not available, this was estimated based on the results from patients who had cataract surgery with a current K and the amount of diopters that the previous monofocal IOL implantation and previously under- surgery had corrected. In this study, the monofocal went a RK surgery. All surgeries took place at IOLs implanted were the AcrySof SN60WF (n = 22, Fernańdez-Vega Ophthalmological Institute (Oviedo, Alcon, USA), AcrySof SN60AT (n = 4, Alcon, USA), Spain), and the written informed consent was obtained and the LUCIA 611 P (n = 2, Zeiss, Germany). 123 Int Ophthalmol (2019) 39:2561–2568 2563

Results analysis On average, the mean logMAR UDVA improved from 0.7 ± 0.3 to 0.4 ± 0.2 at 6 months (P = 0.002) The visual acuity was measured during the preoper- and 0.3 ± 0.2 at 12 months postoperatively ative examination and at 6 months and 1 year after the (P \ 0.001). Nevertheless, comparable UDVA values cataract surgery. The preoperative versus postopera- were obtained between 6 and 12 months postoperative corrected distance visual acuity (CDVA) and the tively (P [ 0.05). As Fig. 2a shows, 25% of the eyes uncorrected distance visual acuity (UDVA) values achieved an UDVA of 0.5 or better before the cataract were used to assess the efficacy and safety of the surgery, and that percentage was doubled at 6 and surgery; meanwhile, the achieved versus the expected 12 months after the cataract surgery. At the same time, refractive outcomes postoperatively were used to Figure 2b shows that about 50% and 65% of the eyes assess the predictability. At the same time, the safety gained more than three lines of VA at 6 and 12 months (postoperative and preoperative CDVA ratios) and postoperatively, respectively. On the contrary, only efficacy (postoperative UDVA and preoperative three eyes lost at least one line of UDVA 12 months CDVA ratios) indexes (decimal notation) were also after the cataract surgery. calculated. The mean logMAR CDVA before the cataract surgery was 0.3 ± 0.2, and it improved up to Statistical analysis 0.1 ± 0.1 after 6 and 12 months postoperatively (P = 0.057). As can be observed from Fig. 3a, almost Data analysis was performed using MATLAB (Math- all eyes achieved a CDVA of 0.5 or better at 6 and Works, Boston, USA). A nonparametric analysis of 12 months after the surgery; meanwhile, almost 65% variance (ANOVA) was used to assess differences of the eyes achieved the same CDVA preoperatively. among the follow-up and preoperative outcomes. Furthermore, about 30% of the eyes achieved a CDVA Differences were considered statistically significant of 20/25 before the cataract surgery, and this value was when the P values were smaller than 0.05. doubled for the same CDVA during the postoperative period. Similarly, 25% of the eyes gained more than three lines of CDVA and less than 10% lost at least one Results line of CDVA by the end of the postoperative visits (Fig. 3b). Finally, the efficacy indices at 6 and In total, 28 eyes of 15 participants were included (ten 12 months were 0.75 and 0.85, respectively. On the males and five females). Table 1 depicts the preoper- other hand, the safety indices were 1.26 and 1.30 at 6 ative and postoperative patient demographics. The and 12 months, respectively. mean participant age at the time of the RK surgery was 35 ± 9 years old, and two eyes had either four, 12 or Refractive results 16 incisions, one eye had either six or 18 incisions, and 20 eyes had eight incisions. On the other hand, the Figure 4a shows the average spherical equivalent mean time between both surgeries was 24 ± 7 years. before the surgery and at 6 and 12 months postoper- Figure 1 shows an eye implanted with a monofocal atively; meanwhile, Fig. 4b and c displays the pre- IOL after RK. Phacoemulsification and IOL implan- dictability diagrams at 6 and 12 months after the tation was performed successfully in all eyes and no cataract surgery, respectively. intra- and postoperative problems occurred. All in all, the mean spherical equivalent changed from - 1.00 ± 6.00 D to - 0.75 ± 1.1 D at Visual acuity results 6 months (P [ 0.05). At 12 months after the surgery, the mean spherical equivalent was comparable to the Figures 2 and 3 show the UDVA and CDVA results, value obtained at 6 months (P [ 0.05). Note that the respectively. In both figures, panel A displays the spherical equivalent before the cataract surgery ranged cumulative proportion of eyes having a given UDVA from - 18.50 to ? 8.5 D, and that interval became or CDVA, and panel B displays the postoperative much tighter by the last postoperative visit (from change in UCVA or CDVA, respectively. - 2.75 to ? 1.0 D). Regarding the predictability outcomes (Fig. 4b and c), about 60% of the eyes were 123 2564 Int Ophthalmol (2019) 39:2561–2568

Table 1 Preoperative and postoperative patient demographics Preoperative 6 months postoperative 12 months postoperative

Age (years) 60 ± 8 (47 to 75) N/A N/A logMAR visual acuity UDVA 0.7 ± 0.3 (0.2 to 1.0) 0.4 ± 0.2 (0.05 to 1.0) 0.3 ± 0.2 (0.05 to 0.7) CDVA 0.3 ± 0.2 (0 to 0.8) 0.1 ± 0.1 (0 to 0.5) 0.1 ± 0.1 (0 to 0.4) Refraction (D) M - 1.00 ± 6.00 (- 18.5 to ? 8.5) - 0.75 ± 1.10 (- 2.5 to ? 1.75) - 0.80 ± 1.10 (- 2.75 to 1.25) J0 - 0.20 ± 0.70 (- 1.9 to 0.8) - 0.10 ± 0.60 (- 1.23 to ? 1.23) - 0.10 ± 0.50 (- 1.23 to ? 1.11) J45 - 0.10 ± 0.40 (- 1.29 to 0.75) - 0.08 ± 0.41 (- 0.98 to ? 1) - 0.094 ± 0.46 (- 1.08 to 0.77) Keratometry (D) Steep 37.51 ± 2.83 (29.50 to 43.50) 37.45 ± 2.62 (30.50 to 42.25) 37.54 ± 2.68 (30.25 to 41.50) Flat 35.64 ± 3.00 (29 to 41.50) 36.23 ± 2.75 (30 to 41.23) 36.02 ± 3.09 (30 to 40.75) Axial length (mm) 27.32 ± 2.07 (24 to 32) N/A N/A ACD (mm) 3.05 ± 0.61 (2.43 to 5.46) N/A N/A IOL power (D) 21.13 ± 6.87 (3 to 33) The values are presented as the mean ± standard deviation, with their corresponding minimum and maximum value within brackets UDVA Uncorrected distance visual acuity, CDVA corrected distance visual acuity, M spherical equivalent, J0 Jackson cross-cylinder with the axes at 180° and 90°, J45 Jackson cross-cylinder with the axes at 45° and 135°, ACD anterior chamber depth N/A not available

lensectomy with a monofocal IOL implantation during 1-year follow-up. UDVA and CDVA improved after the cataract surgery. Speciﬁcally, the mean UDVA improved from 0.7 logMAR to 0.3 logMAR at 12 months after the surgery; meanwhile, the CDVA improved from 0.3 logMAR to 0.1 logMAR by the end of the follow-up. On the other hand, the mean spherical equivalent after 6 months of the surgery was about - 0.75 D, and it barely changed at 12 months after the surgery. These results are similar to those obtained in a previous study, where the authors assessed visual outcomes and Fig. 1 Eye implanted with a monofocal intraocular lens after complications after cataract surgery in 30 eyes with radial keratotomy the previous RK using different incisions lengths [15]. In that study, the patients were implanted with a within ± 1 D at both postoperative visits and about monofocal IOL and had a 3-year follow-up. By the 40% within ± 0.5 D at 6 and 12 months after the ﬁrst year follow-up, the mean BCVA was 0.13 ± 0.08 surgery. logMAR, and the mean spherical equivalent was - 0.51 ± 1.03 D. Unfortunately, that is the only previous study reporting visual outcomes after mono- Discussion focal pseudophakic implantation in RK patients. Thus, based on these results, it can be concluded that this The aim of the present study was to report visual and IOL design offer acceptable visual acuity values in RK refractive results in RK patients that underwent a patients.

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Fig. 2 Uncorrected distance visual acuity (UDVA) results measured preoperatively and at 6 and 12 months after cataract surgery. a The cumulative proportion of eyes having a given UDVA and b the postoperative change in UDVA

In this study, the Double-K formula [4] was used to two formulas. Finally, these authors concluded that calculate the IOL power, and about 60% of the eyes further improvements in the IOL power calculation in were within ± 1.0 D of the target refraction by the end RK were desirable. Discrepancies between studies of the follow-up. In the study published by Zhang et al. could be related to different follow-up periods or [15], the SRK-T formula was used to calculate the IOL differences in the formula used to calculate the IOL power for ten eyes, and the Hoffer-Q modified formula power. Despite all these results, pseudophakic mono- was used for the other 20 eyes. At the last visit, about focal IOL offers acceptable predictability results in 84% of the eyes were within ± 1.0 D of the target RK patients. Nevertheless, further studies could assess refraction with the SRK-T formula, and about 88% of the most efficient IOL formula for this group of the eyes were within ± 1.0 D with the Hoffer-Q patients. modified. On the other hand, Ma et al. [11] assessed In spite all the previous results, it should be taken the accuracy of several IOL power formulas in eyes into account that patients with RK have weaken with RK using the American Society of Cataract and corneas [16] and this could cause refractive regres- Refractive Surgery calculator. The eyes included in sions and visual acuity fluctuations [3]. This could be that study were the previous patients who had cataract the reason why less than 50% of the eyes included in surgery. The IOL calculation methods were the the present study were within ± 0.5 D from the target Double-K Holladay, the optical coherence tomogra- refraction by the end of the follow-up. Besides all this, phy (OCT) formula, the True-K formula, and the the results obtained in this study show that monofocal average of the three formulas. The analyses were done IOL implantation offers acceptable visual acuity and at three different stages: from 3 to 6 weeks after the predictability results. It would be interesting to cataract surgery, from 7 weeks to 3 months and a half consider that slight myopic residual (target for IOL after the surgery, and from 3 months and a half to power calculation) may benefit these patients to 1 year postoperatively. Focusing on the results compensate future hyperopic shift due to RK. Taking obtained for the longest follow-up (up to 1 year), less all of this into account, it can be concluded that a than 75% of the eyes were within ± 1.0 D with the pseudophakic monofocal IOL implantation might be a OCT formula and average methods, and more than good treatment option for RK patients who need 75% of the eyes were within ± 1.0 D with the other cataract surgery. Nevertheless, further studies could

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Fig. 3 Corrected distance visual acuity (CDVA) results measured preoperatively and at 6 and 12 months after cataract surgery. a The cumulative proportion of eyes having a given CDVA and b the postoperative change in CDVA

Fig. 4 Refractive results obtained preoperatively and at 6 and 12 months after the cataract surgery. a The stability of the spherical equivalent and b, c the predictability diagrams at 6 and 12 months postoperatively, respectively have longer follow-up periods or assess the effect of IOL design that offers the best postoperative results in implanting a multifocal IOL in a large population. In RK patients. the end, all these studies will report more evidences Complications after cataract surgery can happen in that could help the selection of the best pseudophakic RK patients. With this regard, a patient who

123 Int Ophthalmol (2019) 39:2561–2568 2567 previously had RK developed a corneal ectasia few reports, there are no studies that focus on the years after the cataract surgery [17]. The treatment assessment of the visual and refractive changes in technique consisted on a combined approach based on RK patients after cataract surgery during a long crosslinking followed by a piggyback technique with follow-up. an add-on toric IOL implantation. Concretely, the add- Cataract surgery in patients with the previous RK on lens consists of implanting an IOL in the sulcus in presents a challenging situation to keep the corneal the presence of a primary lens in the capsular bag. integrity. Concretely, several studies have reported an After the follow-up period, which was 14 months, the incision rupture after conventional phacoemulsifica- patient achieved good refractive outcomes and a visual tion [22–26]. With this regard, Zhang et al. [15] also acuity improvement. Thus, based on those results, the studied the effect of the incision length on the final authors believed that the combined surgical technique result. After 3 years of follow-up, the authors con- of crosslinking followed with an add-on lens implan- cluded that in order to prevent corneal dehiscence tation could be safe and effective for the visual and during the cataract surgery, the more number of refractive rehabilitation of RK ectasia after cataract incisions done on the RK, the smaller corneal incision surgery. length should be. The residual refraction after RK has been corrected The present study assessed the visual and refractive with different techniques, such as contact lenses, recovery after a pseudophakic monofocal IOL implan- phakic IOLs, and corneal laser techniques [13, 18–21]. tation during 1-year follow-up in patients with the Unfortunately, these techniques cannot resolve pres- previous RK surgery. In this study, monofocal IOLs byopia and cannot solve crystalline lens opacities. were implanted, and further studies could assess Three case reports provided evidences about the multifocal lens implantation in RK patients. Finally, surgical treatment of presbyopia and cataract in the follow-up in this study was 1 year, and further patients who previously had a RK [12–14]. On the studies could have longer follow-up periods. one hand, Kim et al. [13] reported the results of two To sum up, pseudophakic monofocal IOL implan- post-RK patients who underwent a refractive lens tation offers good visual acuity recovery and accept- exchange with a multifocal IOL implantation. By the able refractive correction in RK patients after 1-year of end of the follow-up period, both patients reported follow-up. In other words, a pseudophakic monofocal high levels of satisfaction, achieved spectacle inde- IOL implantation might be a good treatment option in pendency for their daily life activities, and good visual patients who undergone RK and need a cataract acuity results (about 20/20 at distance vision and J1 at surgery. Finally, the results presented in this study near vision). On the other hand, Gupta et al. [12] provide evidences that might help to select the IOL assessed the spectacle independency in two RK design that provides the best postoperative results after patients after cataract surgery using a hybrid mono- cataract surgery in RK patients. vision, in which the dominant eye had implanted a monofocal IOL and the non-dominant eye had Compliance with ethical standards implanted a multifocal IOL. These authors reported Conflict of interest The authors declare that they have no that by the end of the follow-up, both patients achieved conflict of interest. good visual acuity results (about 20/20) and spectacle independency. Finally, in another case report, the Informed consent Informed consent was obtained from all individual participants included in the study. authors assessed the possible used of customized toric multifocal IOL in a cataract patient who had a hyperopic shift after RK and crosslinking [14]. After References 1-year follow-up, the patient tolerated well the IOL and achieved good visual acuity (10/10) without any 1. Waring G, Lynn M, Fielding B et al (1990) Results of the refractive regressions. Although these three case prospective evaluation of radial keratotomy (PERK) study reports used different techniques to treat the cataract, 4 years after surgery for myopia. Perk Study Group. JAMA it seems as if multifocal IOLs could achieve good 263:1083–1091 2. McDonnell P, Nizam A, Lynn M, Waring G (1996) Morn- postoperative results in patients with a previous RK. ing-to-evening change in refraction, corneal curvature, and Unfortunately, with the exception of these case 123 2568 Int Ophthalmol (2019) 39:2561–2568

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